COMMENTARY

Mum's Care: Hospital Recommendations Reveal Implicit Racism

Seema Yasmin, MD

Disclosures

April 08, 2019

I am a doctor. I am a daughter. Sometimes these roles collide.

One Monday morning my mum calls me from New York City. She is breathing erratically, and I am worried she will hyperventilate. "I've done something stupid," my mum says. "I've fallen."

Her hand is limp and hanging at a strange angle, and her palm is steadily turning blue. I go into doctor mode. "You're going to take deep breaths like you do in yoga. You're going to hang up the phone. You're going to go to the nearest emergency room, which is Harlem Hospital. They will take good care of you."

Good care. I was taught to treat each patient as if they are my mother, and I need Mum's physicians and nurses to do the same. Mum is 56 years old and proud of how deeply she squats in warrior pose each morning, how easily she flexes her thighs in downward facing dog.

Growing up in a small English town, Mum had an arranged marriage at age 17 and was pregnant with me at age 19. But an act of courage when she was 25 years old secured my future and my freedom. I was 5 years old then, when Mum walked away from our conservative Indian, Muslim community, a community in which women marry in their teenage years and become housewives in their twenties, and went to university with me in tow.

She walked away, faced slurs and estrangement, so that I would be freed from the same oppressive cycle. It was because she left that I could dream of being a doctor, a poet, a professor.

I live in California and my husband works in Manhattan. While Mum is hyperventilating, he rushes uptown and meets her in the emergency room at Harlem Hospital. He sends updates. Mum's wrist is badly broken. The physicians say she needs surgery.

I would not have my mother treated there, one doctor whispers. Transfer her immediately.

As I board the plane to New York City, I text a dozen doctor friends on the East Coast to ask for advice. "Do you know orthopedic surgeons in the area? Where should Mum have surgery?" They text back quickly and connect me with their doctor friends, who email contact information for people they describe as "New York City's best hand surgeon" and "excellent Jewish doctors" in Manhattan and Brooklyn. They recommend NYU-Langone and Cornell. "These are the best places for orthopedics."

The friends of friends are mostly white physicians, and moments before my plane takes off a few of them call to ask where Mum is currently being treated. Harlem Hospital, I say. There is silence on the other end of the phone. "I would not have my mother treated there," one doctor whispers. "Transfer her immediately," says another. I don't ask why Harlem Hospital is not good enough for Mum because I am still a 5-hour plane journey away and I don't want to hear horror stories of nosocomial infections or negligent surgeons.

An Exemplary Hospital in a Rapidly Changing Neighborhood

I call another doctor, Gina, who is Mum's friend. Gina is a black woman who did her residency at Harlem Hospital in the 1980s. She tells me it is a fine institution filled with Columbia University-trained physicians experienced in dealing with trauma.

Rapidly gentrifying West Harlem is a place where white people like to eat soul food, buy brownstones, and read Langston Hughes over a latte, not a place where they choose to have medical treatment. Eleven percent of residents in Harlem Hospital's catchment area are white, according to Census data from 2013, but only 3% of patients at Harlem Hospital are white. Where do white people in Harlem go for medical care?

"You could have sent your mom to Columbia-Presbyterian," one doctor tells me.

"Obviously you're transferring mom to the Hospital for Special Surgery," says another.

When I arrive at Harlem Hospital I learn that Dr Martin Luther King Jr.'s life was saved here, according to plaques and posters on the wall. The check-in clerks are black, and so is every person milling around the small lobby. On the ward, the nurses who direct me to Mum's bed are Nigerian. The young man sweeping the floor is black. The chaplain making his rounds is black. Mum is the only nonblack person on her ward.

I tell Mum I can arrange for her to be seen by a surgeon at a different hospital. "Why?" she says. "Everyone's been great here." My husband, who is black British, a data scientist, and lives in East Harlem, thinks we should stay put. We go over the advice I was given, share data points, and decide racism, not clinical negligence, is the reason I was advised to have her transferred out of Harlem Hospital.

Racism's Persistent Influence in Healthcare

I've experienced both racism and sexism as a physician. Patients have looked me up and down, huffed into their oxygen masks, and asked for a white or male physician. On ward rounds, senior physicians, older white men with white hair, have questioned my ability to answer their questions about complex medical conditions or drug-drug interactions. "But how do you know all of that?" one white physician was prone to asking me in front of my patients.

Patients also experience racism in their hospital beds. Studies have found some white medical students and physicians believe black people experience pain differently than white people, that black people are more tolerant to pain and require less analgesia, and that black people's blood clots differently than the blood of white people.[1]

Should brown and black patients seek care from brown and black physicians who understand our lived experiences and who don't hold racist and magical beliefs about our nerves and our blood? Instead of following leads for "the best doctors" in New York City, who also happened to be white doctors, should I have been seeking out a brown or black doctor to care for Mum?

The Right Decision All Along

On the day of Mum's surgery, a black orderly wheels her to the new part of Harlem Hospital, where we meet her surgical team. Mum's anesthesiologist is a young black woman, her surgeon is an African American man who graduated from Columbia University in 1974 and is director of orthopedic surgery. When I Google him, I find pictures of his family smiling with President Obama and First Lady Michelle Obama in the White House.

The nurse, surgical resident, and patient advocate are all black or brown. Mum says, "As-salamu Alaykum" to the Muslim surgical resident as the team forms a semicircle around her bed. They lower their heads and go through the universal surgical checklist slowly and deliberately. They speak to Mum with compassion, answer all her questions, and reassure her.

I watch the anesthesiologist adjust the bell of her stethoscope and loop the pink rubber tube around her neck. She cannot be mediocre, because to be a black woman in America and to make it to the ranks of senior anesthesiologist in a Level One trauma center requires excellence at every step. None of Mum's team, with their black and brown faces, their accents and given names, can afford to be anything short of brilliant.

I sink into the chair as they wheel Mum into the operating room, and the patient advocate, a tall African American man, stops the gurney and turns to look at me. "Listen," he says. "She's your mother out here, but she's my mother in there."

The morning after surgery, a member of the surgical team visits Mum and checks the four metal pins sticking out of her slender wrist. The clinician is a petite Hispanic woman who says Mum is "a luxury patient for our team. We treat people who have harsh lives." She describes her patient a few doors down: a 17-year-old boy with gunshot wounds, who has been shouting and behaving aggressively toward her.

"I used to work in an inner-city hospital," I say. "Do you want to work elsewhere?" But when she holds Mum's arm in her hands and carefully adjusts the dressing while watching Mum's face, she shakes her head. "I make a real difference here," she says.

Many of the staff have Ivy League degrees and the kinds of credentials that could land them jobs at the hospitals I was advised to take Mum to, places with better-staffed rotating schedules and plusher doctor's lounges. Instead, they choose to provide complex, urgent medical care to patients with multiple comorbidities. And while managing a complicated patient population, they contend with the prejudice of their peers who recommend hospitals with a higher proportion of white physicians and a lower proportion of black patients.

I had been anxious on the flight to New York City, worried that Mum was hurt and that I wasn't being a dutiful daughter. Shouldn't I be pushing Mum to see the so-called top orthopedic surgeons in New York City? Why did I send Mum to a public hospital?

And then I found Mum smiling on the ward, spooning rice and dhaal into her mouth and chatting it up with the Nigerian chaplain who prayed for her one day, and the Ghanaian chaplain who prayed for her the next. I watched the same hospital employee check on her each day to make sure she received halal food and listened to the cleaner, who, as she emptied Mum's trash can, explained that her job was arguably the most critical in the hospital.

Perhaps my decision to send Mum to Harlem Hospital wasn't a clinical decision as much as it was a feeling in my gut, the gut of a brown woman, a Muslim, a physician who has experienced racism from dying people, a person who cannot untangle her clinical judgement from her lived experiences.

That tangle served us well. For 5 days, Mum was loved on, prayed on, and operated on by a group of people invested in her healing and comfort. I had almost doubted my decision to send Mum to Harlem Hospital, but instead I found that my instincts, as both a daughter and a doctor, were correct.

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